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INDIVIDUAL FREEDOM AND THE PUBLIC INTEREST
BY

C. Everett Koop. M.D., Sc.D,
SURGEON GENERAL
OF THE
U.S. PuBLic HEALTH SERVICE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

PRESENTED TO THE FIRST INTERNATIONAL CONFERENCE
ON THE GLOBAL IMPACT oF AIDS”
LonNDON, ENGLAND
Marco 10, 1988
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(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

THANK YOU FOR YOUR INVITATION AND FOR THIS OPPORTUNITY TO
ADDRESS MY COLLEAGUES IN MEDICINE AND PUBLIC HEALTH FROM MANY
OTHER NATIONS.

LET ME PREFACE MY REMARKS WITH A WORD OF APPRECIATION FOR
THE WISDOM SHOWN BY DEAN SMITH AND INDEED ALL THE PEOPLE OF THE
LONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE AND OF THE WORLD
HEALTH ORGANIZATION WHO HAVE BEEN INVOLVED IN PLANNING AND
CARRYING OUT THIS IMPORTANT MEETING,
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TO BEGIN WITH, AIDS IS SUCH A TERRIBLE PUBLIC HEALTH PROBLEM

BECAUSE WE HAVE VERY FEW INSTRUMENTS AT HAND WITH WHICH TO
OPPOSE THE DISEASE. AND THE ONE WEAPON WE DO HAVE -- PUBLIC
INFORMATION AND EDUCATION -- IS EFFECTIVE ONLY WHEN OTHER PEOPLE
USE IT,

NEVERTHELESS, WE IN THE UNITED STATES FIRMLY BELIEVE THAT
ONCE OUR CITIZENS ARE GIVEN THE FACTS AND UNDERSTAND THEIR

SIGNIFICANCE, (THEY MILL TEND TO DO WHAT IS BEST AND WHAT IS RIGHT
»e+ FOR THEMSELVES AND FOR THOSE AROUND THEM, |
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THEY WILL ACHIEVE THE HIGHEST DEGREE OF PERSONAL FREEDOM

CONSISTENT WITH THE PUBLIC INTEREST. THAT MAY SOUND LIKE AN
EXTRAORDINARY “LEAP OF FAITH,” BUT IT’S OURS AND THERE IT IS.

HENCE, A PRIMARY ACTIVITY OF OUR GOVERNMENT, IN PARTNERSHIP
WITH THE PRIVATE SECTOR, IS PUBLIC INFORMATION AND EDUCATION
CONCERNING AIDS. I'D EVEN GO SO FAR AS TO SAY THAT WE‘RE ENGAGED
RIGHT NOW IN ONE OF THE MOST EXTENSIVE EFFORTS IN HEALTH-RELATED
PUBLIC INFORMATION THAT GAVE) BEEN LAUNCHED IN RECENT MEMORY.

AND WHAT ARE WE REALLY TRYING TO DO?
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BASICALLY, WE’RE TRYING TO CONVINCE OUR CITIZENS THAT THE

THREAT OF AIDS IS REAL AND IT IS HERE, AND WE'RE TRYING TO
HELP THEM AVOID THE KINDS OF HIGH-RISK BEHAVIOR BY WHICH A PERSON
CAN BECOME INFECTED WITH THE AIDS VIRUS.

GIVE PEOPLE THE FACTS ... LET THEM MAKE A FREE CHOICE ON THE
BASIS OF THOSE FACTS ... AND THEY INDIVIDUALLY AND COLLECTIVELY
WILL BENEFIT, THAT'S THE THEORY.

BUT ON THIS VERY POINT, LET ME BE THE FIRST AMONG US TO
STRIKE HIS OWN BREAST ... IN SORROW AND FRUSTRATION. AND LET ME
TELL YOU WHY,
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FIRST, A LITTLE BACKGROUND.

_ IN THE UNITED STATES, WE‘VE BEEN CONCERNED FOR MANY YEARS
ABOUT THE HIGH RATES OF UNWANTED PREGNANCIES AMONG YOUNG BLACK
WOMEN, PARTICULARLY THOSE LIVING IN OUR CENTRAL CITIES. AND
WE’VE TRIED VERY HARD TO REACH THESE YOUNG WOMEN WITH IMPORTANT
PUBLIC HEALTH INFORMATION,

WE’VE TRIED TO EXPLAIN REPRODUCTIVE BIOLOGY TO THEM,

WE'VE ENCOURAGED THOSE WHO DO GET PREGNANT TO SEEK GOOD
PRENATAL CARE, |
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WE'VE URGED THESE YOUNG WOMEN TO RETURN TO THE MAINSTREAM OF
PUBLIC EDUCATION DURING THEIR PREGNANCY AND AS SOON AS POSSIBLE
AFTER THEY HAVE THEIR BABIES.

WE'VE ALSO ENCOURAGED THEM TO RAISE THEIR OWN SELF-IMAGE ...
TO THINK BETTER OF THEMSELVES AND OF WHAT THEY MAY HAVE TO OFFER
ves AND NOT TO RISK ALL. THE PROMISES OF THEIR FUTURE IN ONE |
PREMATURE SEXUAL EMBRACE.

WE'VE TRIED.... AND I CAN’T TELL YOU HOW DEEPLY TROUBLED I
AM BY OUR LIMITED SUCCESS.
g
EACH YEAR TENS OF THOUSANDS OF OUR YOUNG BLACK WOMEN BECOME

PREGNANT TOO SOON ... THEY DO NOT RECEIVE GOOD PRENATAL CARE --
FOR WHATEVER REASONS, SOME OF IT OF THEIR OWN MAKING, BUT A LOT
QF THE FAULT IS OURS -- AND THEN THEY STRUGGLE TO REBUILD THEIR
YOUNG LIVES, BOTH AS A CHILD AND AS A PARENT OF A CHILD.

I WOULDN'T RECOUNT THIS PROBLEM FOR YOU TODAY, EXCEPT THAT
ONE OF. THE SADDEST AND MOST DIFFICULT ASPECTS OF. THE AIDS
EPIDEMIC IS THE GROWING NUMBER OF BABIES BORN WITH AIDS WHOSE
MOTHERS ARE YOUNG AND BLACK.
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NATIONALLY, ALMOST TWO OF EVERY THREE BABIES BORN WITH uns |

ARE BLACK. IN SOME CITIES, OVER 80 PERCENT ARE BLACK.

THESE BABIES ARE BORN TO YOUNG WOMEN TO WHOM WE'VE BEEN
BEAMING OUR PUBLIC HEALTH MESSAGES FOR YEARS, BUT WHO
HAVEN'T REALLY UNDERSTOOD THEM -- IF, INDEED, THEY EVER RECEIVED
THEM IN THE FIRST PLACE. AND THAT ITSELF IS DOUBTFUL.

AND LET ME OFFER A SECOND EXAMPLE.
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WE KNOW THAT ONE OF EVERY FOUR PERSONS WITH AIDS IN THE

UNITED STATES IS AN INTRAVENOUS DRUG ABUSER. DRUG ADDICTION HAS

BEEN ONE OF THE MAJOR HEALTH PROBLEMS OF OUR SOCIETY FOR DECADES

-r. BUT GETTING WORSE, IT SEEMS, IN THE PAST FEW YEARS
_—

ONCE AGAIN, WE’VE expen A GREAT DEAL OF OUR NATIONAL

TREASURY (INTO EFFORTS TO REDUCE OR ELIMINATE DRUG ADDICTION,

PARTICULARLY AMONG OUR MINORITY AMERICANS, BLACKS AND HISPANICS

IN PARTICULAR. AND ONCE AGAIN -- WE‘VE BEEN LESS THAN

SUCCESSFUL.
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DESPITE TREATMENT CLINICS AND OUTREACH WORKERS AND TOUGHER

LAW ENFORCEMENT AND, NOW, GANGLAND-STYLE ASSASSINATIONS WITHIN
THE DRUG CULTURE ITSELF, THE LEVEL OF DRUG ADDICTION IS STILL
UNACCEPTABLY HIGH.

AND, THEREFORE, THE POTENTIAL FOR THE SPREAD OF AIDS AMONG
I.V, DRUG ABUSERS IN THE UNITED STATES REMAINS UNACCEPTABLY HIGH —
AS WELL.

AS SURGEON GENERAL AND AS AN AMERICAN CITIZEN, ( AM HAUNTED
BY THESE AND OTHER EXAMPLES OF OUR INABILITY OVER THE YEARS TO DO

THE BEST POSSIBLE PUBLIC HEALTH JOB FOR THOSE OF OUR CITIZENS IN
THE WORST POSSIBLE CIRCUMSTANCES.
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] SAID THAT I1’D BE THE FIRST TO PUBLICLY BEAT MY BREAST.

AND I KEPT MY PROMISE. BUT I SUBMIT THAT EACH HEALTH OFFICIAL
HERE TODAY COULD PROBABLY MATCH MY EXAMPLES WITH EQUALLY
RISTURBING ONES OF HIS OR HER OWN,

I BEGAN MY REMARKS BY NOTING THAT IN OUR SOCIETY THE
INDIVIDUAL CAN ACHIEVE A MEASURE OF FREEDOM TO THE EXTENT THAT
HE OR SHE IS GIVEN -- AND UNDERSTANDS -- THE FACTS ... IN OUR
CASE, THE FACTS OF LIFE AND HEALTH.

CONVERSELY, THE PERSON IN OUR SOCIETY WHO DOES NOT KNOW THE
FACTS OF LIFE AND HEALTH -- FACTS, BY THE WAY, THAT ARE KNOWN BY
MOST OF HIS OR HER NEIGHBORS -- THAT PERSON IS NOT A FREE
INDIVIDUAL.
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AND FRANKLY I'M NOT CONVINCED THAT OUR AIDS INFORMATION

CAMPAIGNS -- DIRECTED FOR THE MOST PART AT THESE SAME HIGHLY
VULNERABLE COMMUNITIES -- WILL FARE MUCH BETTER.

LET US ADMIT THE OBVIOUS: WE'VE BEEN DOING SOMETHING WRONG
IN THE PAST. AND NOW WE MUST FIND OUT WHAT THAT IS AND WE MUST
CORRECT IT,

IF WE DO NOT -- IF WE CONTINUE TO CONDUCT OUR PUBLIC HEALTH
AFFAIRS ON THE BASIS OF “BUSINESS AS USUAL” -- WE CANNOT HOPE TO
RID OUR COUNTRIES AND THE WORLD ITSELF OF THE TERRIBLE DISEASE OF
AIDS,
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WE WILL FAIL ... ONCE MORE.

AND THEN, I MUST WONDER, HOW “FREE” WILL ANY OF US REALLY
BG? -

I THINK WE HEALTH PROFESSIONALS NEED TO ASK THESE QUESTIONS
NOW OF OURSELVES, DURING THIS VERY DIFFICULT PRE-VACCINE PERIOD
OF THE AIDS EPIDEMIC. WE MUST DO THAT, IF WE HAVE ANY HOPES AT
ALL OF MAKING EFFECTIVE USE OF AN AIDS VACCINE WHEN ONE FINALLY
ARRIVES, AND I FIRMLY BELIEVE THAT ONE DAY IT WILL,
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BUT WHEN SUCH A VACCINE DOES ARRIVE ... THEN WHAT?

| I NEED NOT REMIND THIS DISTINGUISHED AUDIENCE THAT THE WORLD
DOES NOT YET HAVE A SUPERB RECORD IN REGARD TO THE MANY VACCINES
THAT ARE NOW AT HAND.

FOR EXAMPLE, THERE IS A VACCINE FOR EACH OF THE 6 MAJOR
COMMUNICABLE DISEASES OF CHILDHOOD. THESE VACCINES HAVE BEEN
GENERALLY AVAILABLE IN MOST OF THE INDUSTRIALIZED WESTERN WORLD.
HENCE, THE CHILDREN IN THOSE NATIONS HAVE A HIGH DEGREE OF
PROTECTION AGAINST SUCH DISEASES.
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BUT THESE VERY SAME VACCINES HAVE YET TO FULLY PENETRATE

MANY OTHER COUNTRIES OF THE INDUSTRIALIZED EAST AND WEST, MUCH
LESS THE VILLAGES AND CROSS-ROADS OF THE LESS DEVELOPED AND
DEYELOPING WORLD. ©

IN FACT, FROM MY VANTAGE-POINT OF HAVING ATTENDED MANY WORLD
HEALTH ASSEMBLIES, I BELIEVE IT IS SAFE TO SAY THAT THE DELIVERY ~
OF IMMUNIZATION SERVICES THROUGHOUT THE DEVELOPING WORLD IS STILL
ONE OF THE GREAT TECHNOLOGICAL CHALLENGES FACING CONTEMPORARY
MEDICINE AND PUBLIC HEALTH.
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THE DEVELOPMENT OF AN AIDS VACCINE MAY NOT BE OUR GREATEST

CHALLENGE AFTER ALL, THE DELIVERY OF THAT VACCINE ... WHERE IT
IS NEEDED ... MAY BE A MUCH TOUGHER CHALLENGE. IT WILL REQUIRE
NEHSYSTEMS OF TRANSPORTATION AND REFRIGERATION ... OF SECURITY
.s+ AND COST CONTROLS ... AND SO ON,

BUT IT WILL ALSO REQUIRE PUBLIC ATTITUDES OF TRUST ... OF
TOLERANCE ... AND OF UNDERSTANDING ... ATTITUDES BASED UPON THE
WIDEST POSSIBLE DISSEMINATION OF THE FACTS.
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BUT I WOULD SUGGEST THAT ALL THOSE REQUIREMENTS MUST BE MET

BEFORE A VACCINE CAN BE SUCCESSFULLY DELIVERED TO AN ENTIRE
PEOPLE. HOWEVER, YOU AND I KNOW THAT THEY ARE NOT BEING MET NOW
IN-MANY PARTS OF THE WORLD ... IN DEVELOPED AS WELL AS DEVELOPING
COUNTRIES.

AS A RESULT, AN ESTIMATED 5 MILLION CHILDREN DIE EVERY YEAR
OF THESE 6 INFECTIOUS DISEASES, AND ABOUT AN EQUAL NUMBER OF
CHILDREN ARE INFECTED BUT MANAGE TO SURVIVE TO CARRY THE SCARS
OF THEIR DISEASE FOR THE REST OF THEIR LIVES,
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IN THIS REGARD, I WOULD HAVE TO SAY THAT ONE OF THE MOST

IMPORTANT AIDS-RELATED EFFORTS OF THE WORLD HEALTH ORGANIZATION
TODAY IS ACTUALLY THE “EXPANDED IMMUNIZATION PROGRAMME.” THIS
PROGRAN IS MAKING A SIGNIFICANT DIFFERENCE IN THE HEALTH STATUS
OF CHILDREN WHEREVER IT HAS BEEN GIVEN A CHANCE TO WORK, WHETHER
IN AFRICA, ASIA, OR CENTRAL OR SOUTH AMERICA. THE UNITED STATES
IS 100 PERCENT BEHIND IT.

BUT I SUGGEST THAT THE TREMENDOUS EFFORT REQUIRED SO FAR TO
MAKE THIS PROGRAM WORK MAY BE THE VERY SIGNAL WE NEED TO REMIND
US OF THE SIZE OF THE TASK AHEAD OF US, IF WE WISH TO EXPLOIT THE
ARRIVAL OF AN AIDS VACCINE, AS SOON AS IT APPEARS.
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SO WE HAVE AHEAD OF US NOT ONLY A MAJOR BIOMEDICAL CHALLENGE

-- THAT IS, THE DEVELOPMENT OF A SAFE AND EFFECTIVE AIDS VACCINE
-- BUT WE ALSO HAVE THE CHALLENGE OF RENOVATING AND REJUVENATING
ENTIRE NATIONAL SYSTEMS OF HEALTH CARE, MAKING THEN CAPABLE OF
DELIVERING TO EVERY CITIZEN CERTAIN ESSENTIAL FACTS AND IDEAS --
AS WELL AS VACCINES -- SO THAT THEY THEMSELVES MAY FREELY CHOOSE
TO LIVE BETTER AND BE HEALTHY.

AND, FROM THE EXERCISE OF THAT PERSONAL,, INDIVIDUAL FREEDOM
WILL COME, I AM SURE, ALL THE GREAT PUBLIC BENEFITS WE DESIRE --
NOT THE LEAST OF WHICH WOULD BE THE CONQUEST OF THE DISEASE OF
AIDS.

THANK YOU.
HH EH #